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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530083
Report Date: 04/08/2024
Date Signed: 04/08/2024 12:19:43 PM

Document Has Been Signed on 04/08/2024 12:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ESPERANZA RESIDENTIAL CAREFACILITY NUMBER:
365530083
ADMINISTRATOR/
DIRECTOR:		CYNTHIA LEGGS-JONESFACILITY TYPE:
735
ADDRESS:9868 VIA ESPERANZATELEPHONE:
(909) 912-9060
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91737
CAPACITY: 4CENSUS: 4DATE:
04/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:44 AM
MET WITH:Tyhesha HarpsTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Administrator Tyhesha Harps and was granted entry to the facility. At the time of the visit there was one (1) staff present, and four (4) clients were attending Day Program.The facility is a four (4) bedroom, two and a half (2.5), bathroom home, with a kitchen/dining area, living room, with open driveway. The facility is an Adult Residential Facility (ARF) vendorized by inland regional center. Licensed capacity is (4) current census (4). LPA was accompanied by Facility Administrator, to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client’s bedrooms; operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were and observed the water temperatures in the bathrooms to be 119.6 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept inside kitchen cabinet inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.



Record Review: LPA reviewed four (4) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ESPERANZA RESIDENTIAL CARE
FACILITY NUMBER: 365530083
VISIT DATE: 04/08/2024
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Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Tyhesha Harps.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024
LIC809 (FAS) - (06/04)
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